Research reportSigns and symptoms of mania in pure and mixed episodes
Introduction
There have been remarkably few systematic studies of manic signs and symptoms in large cohorts of patients. Although a clinical consensus on the classical signs and symptoms of mania developed early, debate over the validity of manic subtypes continues. As a result, the prevalence of important subtypes in clinical populations of manic patients has not been established. Manic state rating instruments also are incomplete because they do not adequately represent the signs and symptoms associated with manic subtypes, of which the mixed bipolar state is the most important. In this report we start at the foundation of defining mania by reviewing statistical analyses of the validity of the manic syndrome, comparing the distinctively manic symptom profiles reported in cohorts of subjects with heterogeneous Axis I diagnoses. We then review conceptual models of mania and present an overview of studies of manic subtypes, which we compare with the DSM-III-R definition of Bipolar Disorder, mixed. Finally, we compare and contrast current mania rating scales, highlighting differences in their inclusion of classical signs and symptoms of mania, and their omission of signs and symptoms relevant to mixed states. Based on these reviews, we selected 20 signs and symptoms representative of both “classical” mania and of mixed bipolar states to include in a mania rating instrument. Using this new research instrument, we evaluated a cohort of acutely manic patients and studied the frequencies of those signs and symptoms in a large cohort of Bipolar, manic and mixed, patients.
Section snippets
Validity of signs and symptoms of the manic syndrome
Although rich descriptions of mania abound in the literature (e.g. Kraepelin, 1921, Winokur et al., 1969), few statistical studies address the definition of a manic syndrome distinct from other Axis I disorders. Four factor analytic studies reported on signs and symptoms evaluated in subjects with various diagnoses, including mania (Moore, 1930Wittenborn, 1951Kitamura et al., 1995Altman et al., 1994).
A comparison of those four studies is shown in Table 1. All four studies identified a separate
Conceptual models
It is impossible to discuss mania and its subtypes without considering conceptual models of bipolar disorder. The relationship between depression and mania is an issue that has never been resolved by the field, and that failure is directly responsible for much of the confusion about mixed states.
Despite the widespread acceptance of the “bipolar” conceptualization of manic-depressive disorder, as evidenced by the incorporation of the term “bipolar” into the diagnostic nomenclature, the continued
Subtypes of mania
Confusion about subtypes of mania abounds. Despite the early recognition of different manic states by experienced clinicians, few systematic studies of the variations in manic symptomatology have been conducted. Early descriptions of mania pointed clearly to subtypes of the disorder. For example, Davidson (1957)quotes one of the earliest descriptions of “mania” given by Aretaeus the Cappadocian, who stated “the form and ways in which mania manifests are manifold. Some are cheerful and like to
Mania rating scales
Numerous mania scales exist. That is often a sign that none of the alternatives is very good, and certainly no standard instrument has emerged by consensus in the field. None comprehensively includes signs and symptoms relevant to mixed mania. Many even overlook important signs and symptoms of classical mania. A comparison of signs and symptoms in these mania scales is presented in Table 3. It is apparent in Table 3 that the current rating scales for mania provide very variable coverage even of
Scale construction and face validity
Following our review of studies of manic signs and symptoms and a comparison of current mania scales, we developed a research instrument, the Scale for Manic States, which includes signs and symptoms relevant to both pure mania (15 items) and mixed mania (5 items). Euphoria, irritability, aggression, motor activation and grandiosity were predominant in the general validation studies we reviewed (Table 1) and are all included. Also included from those studies were decreased sleep,
Rating procedure
Ratings were made by clinicians familiar with the management of manic patients and were based on direct interviews of at least 20 min duration. This requirement is the same as Hamilton (1960)stipulated for his depression rating scale. Additional information from the clinical record and from staff observations was incorporated in the rating process (e.g. recent episodes of anger or inappropriate sexual behavior or insomnia). Ratings related to a 3–4 day period of time in order to sample
Concurrent validity and reliability
Concurrent validity of the Scale for Manic States was determined by comparison with the Beigel-Murphy Manic-Scale Rating Scale (Beigel et al., 1971) and with clinical global assessments. Thirty five sets of concurrent ratings were collected on inpatients who carried a DSM-III-R diagnosis of Bipolar Disorder, mixed or manic, or in remission. Ratings included the Scale for Manic States, the Beigel-Murphy Manic-State Rating Scale, and a clinical global impression of manic severity on a scale of
Statistical analysis
Data were analyzed using both a low threshold and a high threshold for the presence of a given sign or symptom. The low threshold was a score of 1. At this threshold the sign or symptom was considered present but of minimal severity. The high threshold was a score of 2, at which the sign or symptom was indisputably present. Frequencies of each sign or symptom were then calculated for the entire cohort and by DSM-III-R diagnosis of Bipolar Disorder, manic and mixed. Differences between these two
The study cohort
We studied 316 consecutively admitted manic patients on the adult and geriatric inpatient services at John Umstead Hospital. The 316 patients included 148 males and 168 females. There were 273 (86%) diagnosed Bipolar Disorder, manic, and 43 diagnosed Bipolar Disorder, mixed, using DSM-III-R criteria. The mean age was 42.2, SD 14.0, with a range of 18–82 years. The sample included 180 whites, 134 blacks, 1 oriental and 1 American Indian. The mean total symptom score was 34.6 SD 9.8 with a range
Results
Thirty five sets of concurrent ratings were obtained by one of the authors (F.C.) using the Scale for Manic States, the Beigel-Murphy Manic-State Rating Scale and clinical global impression. By DSM-III-R criteria, the episodes rated included Bipolar Disorder, manic (n=27), Bipolar Disorder, mixed (n=6), and Bipolar Disorder, in remission (n=2). The sample included 17 females and 18 males. The mean age of these patients was 40.8 years (range 21–75, SD 13.3). Correlations of the Sale for Manic
Discussion
Our review suggests that the face validity of signs and symptoms comprising the manic syndrome, which derives from classical clinical descriptions, is supported by several limited statistical studies in which the manic syndrome appeared as a separate factor of psychopathology (Table 1). The classical syndrome of mania is easily recognized, clinically or statistically, even when only a few manic subjects are present in a large population of psychiatric patients (e.g. Kitamura et al., 1995). The
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2020, Psychiatric Clinics of North AmericaCitation Excerpt :This factor often is more frequent in mixed than pure mania,8 though not in all studies.15 It includes irritability, subjective and overt anger, uncooperativeness, impatience, suspiciousness, hostility, and aggression, and is present in 22.7% to 72% of manic patients.32,39 This factor showed a variable pattern, sometimes covarying with manic elation symptoms (ie, euphoria, increased self-esteem, and grandiosity)16,17,19,21,22,24,28,31,37 or dysphoria,13,17,23,27,36 and sometimes presenting as an independent factor.14,18,20,26,30,38